by Scott Graybow
The term “analytic action” assumes new complexity when we use it to enhance meaningful discourse about our unsettling and turbulent political reality. It opens doors to the possibility of kindling a deeper connection to parts of our psychoanalytic heritage, such as Freud’s free clinic movement. It brings to mind concerns expressed by early psychoanalysts Otto Fenichel, Wilhelm Reich, and Erich Fromm about the way sick societies produce troubled minds. Most importantly, it introduces two pressing questions. First, what issues occurring outside the consulting room demand analytic action? Second, what renders “action” outside the consulting room “analytic”?
With that in mind, I would like to share some ideas and experiences I hope constitute one example of a form of analytic action that enriches, but in no way forecloses, other understandings and approaches. The analytic action I would like to discuss highlights both an intervention and the dilemma that necessitates it. I conceptualize this dilemma as a unique case of gaslighting geared specifically toward us and our patients. The dilemma I am referring to is the neoliberal phenomenon known as evidence-based therapy (EBT).
Let me assure you, I am not saying EBT’s stated goal of researching the effectiveness of mental health treatment is “fake news.” Nor am I implying that research demonstrating the benefits of non-psychoanalytic treatment should be dismissed as “alternative facts.” What is concerning is the way in which EBT has come to refer almost exclusively to short-term, symptom-focused, manualized treatments, such as cognitive behavioral therapy. This is the case despite the existence of a large body of scientific evidence demonstrating the clinical efficacy of psychoanalytic and psychodynamic treatment. 1, 2
This misrepresentation of research outcomes is only the beginning of the problem.
The problem becomes clearer when we examine EBT in the context of its political economy. This expanded lens reveals how EBT comfortably conforms with neoliberal standards of management, measurement, and efficiency. These standards state that truth is not true, science is not science, and what is counted does not count unless it can be measured using minimal resources to provide maximal return. This is readily apparent in clinics that serve poor patients while operating in a world where nothing, not even social services and mental health care, is exempt from free market definitions of progress and efficiency. In these settings, EBT’s clinical efforts cannot be separated from its role in reproducing the attitudes and goals of the society that produced it. Like budget cuts and other neoliberal austerity measures, EBT means decreased access to relationship-based psychotherapy and the dominance of corporate buzzwords like “responsibility” and “motivation” among administrators and clinicians alike.
But how is this gaslighting?
Gaslighting puts pressure on its victims, driving a wedge between them and the truth, in the process putting the responsibility on them to prove they do not deserve such abuse in the first place. Representative Alexandria Ocasio-Cortez, in a statement that has since gone viral, gives us a perfect example. In response to her attempts to move Congress toward a greater role in protecting the environment, she was accused of being elitist. She calls out the twisted irony of this accusation, describing how it results from her efforts to help her poor constituents by putting limits on the elite. She explains it is the poor who disproportionately suffer the effects of pollution, the existence of which is a byproduct of the industrial process that enriches the elite and enables them to provide campaign funding to the very Republican lawmakers who label her an elitist in an attempt to discredit her.
A similar dynamic plays out for us. Gaslighting through EBT puts us in a position where we must prove we can help as well as disprove the belief that we cause harm. Like Representative Ocasio-Cortez, we are tasked with not only conveying the truth but also disproving a lie.
This is particularly the case for those of us who work in the kind of clinical settings I mentioned earlier. In these places, EBT gaslighting rationalizes austerity using the language of empirical science. It infers clinicians who speak in favor of relationship-based therapy — not budget cuts, staff reductions, time-limited therapy, and increased caseload sizes — are the real barrier to care. What psychodynamic clinician who has worked in an agency has not heard the retort, “The patient is struggling! What do you mean you listened to him? Why aren’t you teaching him skills?!”
Meanwhile, the agency portrays itself not as the bearer of bad news but the protector of its needy and disadvantaged patients, who can rest assured they will have access to only the most evidence-based care. Clinicians who say even the poor can afford to explore the unconscious are the real elitists, evidence of which is their privileged ability to casually disregard the fast and sure relief provided by EBT.
It is this dilemma that I believe requires analytic action.
I say analytic action is required because only psychoanalysis offers a means to understand and work with the final piece of EBT gaslighting — by this I mean the part of the dilemma that is personal and seemingly irrational. For example, at a conference I attended, a speaker who practices EBT told us a patient of his was terminating in order to pursue treatment with another clinician. He explained this was not a big deal because the patient could get the exact same treatment anywhere from anyone. He was quite content with this state of affairs in which his work is considered effective due to it being devoid of any qualities unique to him.
Analytic action becomes necessary when sociological or economic theories fail to account for the contradictions that frequently define the lived experience of social problems. For example, Marxism enables us to identify and study the dialectical tension between EBT’s reliance on objective scientific methods and its origin in and contribution to neoliberal efforts to ration access to care. Through the concept of alienation, Marxism even offers ideas about the psychological consequences of rendering people’s labor devoid of opportunities to develop their individual uniqueness. What it does not do is help us understand why, at times, the exploitation that accompanies a social problem is in fact a source of pleasure and purpose. This is the case, for example, when exploited workers find satisfaction not by striking but by reporting to work, or poor voters experience a feeling of strength when they cast their ballot for the candidate whose goal is to cut taxes for the rich. While material conditions can often explain these behaviors (threats of retaliation for striking, lack of information necessary to make an informed vote), they cannot account for the pleasurable emotions involved — Marxism sheds light on why the speaker at the conference is alienated, but it cannot account for how he is content with his alienation.
Psychoanalysis exists at the nexus of social and personal emancipation. Of course, phenomena like EBT, a strike, or an election cannot be analyzed. What psychoanalysis can do is put us on the road toward understanding why individuals engaged with these phenomena relate to them in ways that are inexplicable from a purely economic or sociological perspective. Through the study of the unconscious, it enables us to scientifically locate meaning in individual feelings and behaviors that other approaches can only see as irrational.
The “analytic” in “analytic action” is acknowledgment of the psychodynamic process that occurs as the mind seeks satisfaction in the face of material conditions resulting from the way in which society is arranged. Regarding EBT gaslighting, it means appreciating the role of the unconscious in helping us find satisfaction as we attempt to function within a mental health industry that privileges research and practices grounded in the assumption that empirical truth and neoliberal subjectivity are one and the same. It is action that promotes the knowledge that we can be victims of our environment and of ourselves. Not only are we at risk of becoming prisoners to EBT gaslighting in our clinics, but we are also at risk of becoming prisoners to it in our minds.
I found this to be the case during my outreach work with graduate students on behalf of an organization promoting psychoanalysis in clinical social work. Some students I met were clearly bothered by the state of mental health care and eagerly shared their feelings about EBTs contradictions. These students expressed pain about supervisors telling them not to document that they listened to patients because listening is not part of evidence-based care. They described feeling alienated in classrooms where failure to report that their fieldwork with patients consists of measurement tools and treatment manuals can result in a lower participation grade. Other students had never given such things any thought or felt bothered by them. They came to the outreach session because they were curious to hear about my claim that psychoanalysis — which they understood to be an indulgence for the privileged — is, in fact, relevant to poor social work clients and the services they receive from social workers like themselves.
We talked, listened to one another, and along the way, opportunities arose for facts to be shared. What facts did I share with these students? First, facts disproving the myth that psychoanalysis lacks scientific research speaking to its clinical effectiveness. Second, facts disproving the myth that psychoanalytic theory and practice have nothing to say about the formative role of material conditions or topics like culture and race.
I hope this short description of my efforts to help graduate students face EBT gaslighting inspires you to connect with your version of analytic action! What I am proposing is nothing new. There is literature about the inaccuracies of the EBT label3, about EBT’s overlap with neoliberal austerity measures4, and about how psychoanalysis expands the practical and theoretical possibilities of important social change theories.5, 6, 7 What I have attempted to do is bring these knowledge areas into conversation so we might better respond to a pressing social problem. Along the way, I have hopefully provided a useful way of thinking about this magazine’s primary focus: analytic action outside the consulting room. ■
Scott Graybow, PhD, LCSW, completed the psychoanalytic psychotherapy program at the New York Contemporary Freudian Society. He will begin the training program in adult psychoanalysis there in January 2020. He is a member of the International Erich Fromm Society and on the advisory board of the American Association for Psychoanalysis in Clinical Social Work. He is editor of Progressive Psychoanalysis as a Social Justice Movement (Cambridge Scholars Publishing, 2017) and the author of articles about the political economy of mental health.
(1) Jonathan Shelder, The Efficacy of Psychodynamic Psychotherapy
(2) Mark Solms, The Scientific Standing of Psychoanalysis
(3) Jonathan Shedler, Where’s the Evidence for “Evidence-Based” Therapy
(4) Farhad Dalal, The Cognitive Behavioral Tsunami: Managerialism, Politics, and the Corruptions of Science
(5) Otto Fenichel, Psychoanalysis as the Nucleus of a Dialectical-Materialistic Psychology
(6) Wilhelm Reich, Dialectical Materialism and Psychoanalysis
(7) Erich Fromm, The Crisis of Psychoanalysis: Essays on Freud, Marx, and Social Psychology
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